=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669337705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC MENTAL HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2025
-----------------------------------------------------
Last Update Date | 12/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 BI STATE PLZ # 841
-----------------------------------------------------
City | OLD TAPPAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-7003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-758-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 BI STATE PLZ
-----------------------------------------------------
City | OLD TAPPAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-7003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-758-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | EZINNE EZETE
-----------------------------------------------------
Credential | APRN, PMHNP-BC
-----------------------------------------------------
Telephone | 860-758-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------